scottish history – Page 32 – Outlander Anatomy

August 25, 2015August 31, 2015

Fun Fact – Borborygmi

Learn more about borborygmi in Anatomy Lesson #16: Jamie’s Belly or Scottish Six-Pack!

And from Outlander book:

I wasn’t at all thirsty, but the faint scent of honey reminded me that I was starving, and had been for some time. My stomach gave an embarrassingly loud growl, protesting my neglect. “Hey, then, Jamie-lad! Hungry, are ye? Or have ye a set of bagpipes with ye?” shouted Rupert, mistaking the source of the noise. “Hungry enough to eat a set of pipes, I reckon,” called Jamie, gallantly assuming the blame. A moment later, a hand with a flask came around in front of me again. “Better have a wee nip,” he whispered to me. “It willna fill your belly, but it will make ye forget you’re hungry.”

See Jamie stave off Claire’s borborygmi in Outlander, Starz, episode 101: Sassenach!

The deeply grateful,

Outlander Anatomist

August 18, 2015August 19, 2015

“The Savvy Sniffer – Claire’s Nose Knows!”

Welcome, students to Anatomy Lesson #28 – The Nose! Oh, you don’t think the nose sounds very interesting? Well, please read on because this lesson contains surprising, startling and shocking info about the human proboscis.

Is the nose important to society? You bet! There is a mess of English idioms about the nose including: as plain as the nose on your face, nose to the grind stone, turn nose up, brown nose, follow one’s nose, cut one’s nose off to spite one’s face, count noses, nose for gossip, win by a nose, keep nose out of business, no skin off one’s nose, nose about, nose to the ground, look down one’s nose at, nose around, and nose-to-nose. Clearly, the nose is a clever conduit to convey important social messages.

Oh, and let us not forget the nose-out-of-joint idiom! Claire and Jamie are clearly in that realm going at it “Down by the Riverside.” Pretty simple really: Jamie expects an apology and Claire isna giving one (Starz episode 109, The Reckoning)! He told her to STAY PUT but she doesna have to do what he says! She’s his wife and she doesna like that one bit! Whew, their passionate noses are fully engaged in this battle of wills!

Those who read Diana’s books know that Claire is endowed with a very keen sniffer. Her nose catalogues a staggering array of smells including but certainly not limited to: alcohol, bat guano, bitter almonds, blood, clover, feces, grass, herbs, honey, hops, ink, laundry starch, opium, pickled herring, pine needles, pine tar, pitch, pus, raw sewage, resin, road dust, seasickness, soap, sulfur, wine, wood smoke, yeast and last but not least, male sweat! Jamie, Himself offers a fine flattering appraisal of Claire’s nose (Voyager book)!

“’You smell of ink.’” He smiled slightly, stepping back and running his hand through his hair. ‘You’ve a nose as keen as a truffle pig’s, Sassenach.’ ‘Why thank you, what a graceful compliment,’ I said.

At the base of Craigh na Dun we see more proof of her superb sniffing skills. Claire’s knowing nose encounters Frank dressed in 18^th century soldier garb (Starz episode 101, Sassenach). Oops, it isn’t Frank, but his six-time great grand paternoster: Jonathan Randall, Esquire, Captain of his Majesty’s Eighth Goons, er, Dragoons! Ugh, he’s too close for comfort as Claire analyzes his personal plethora of peculiar odors:

“My captor, whoever he was, seemed not much taller than I…. I smelled a faint flowery scent, as of lavender water, and something more spicy, mingled with the sharper reek of male perspiration.”

His miasma of lavender and male sweat doesna appeal to Mistress Claire; her nose knows a real stinker when it sniffs one. But, dinna despair lassie, a braw and bonny laddie is coming your way pronto! Ye will like the whiff of him. No problema!

Anatomy of the human nose is fascinating so let’s get started! Nose and chin are typically the most projecting parts of the face. In anatomy, the nose is divided into external nose, the visible projecting part, and internal nose, the part deep to the surface. In anatomy, the nose belongs to the respiratory system because it serves as a passageway for air flow during respiration: nitrogen, oxygen, carbon dioxide, and argon, along with trace elements and other particles move through the nose on their way into and out of the lungs.

The external nose has a root that is continuous with the forehead (Photo A – red arrow). The tip of the nose is its apex. The paired nostrils are the nares. The bridge is formed of bone and cartilage and the alae (pl. – Latin meaning wings) are the nasal flaps. Nasal skin is typically thin (Anatomy Lesson #5 and Anatomy Lesson #6) and adheres tightly over the alae but elsewhere is quite moveable.

Photo A

The skeleton of the external nose is composed of bone, cartilage and fibro-fatty tissue that mimics the external shape. The bridge includes a pair of small nasal bones (Photo B) that form non-movable joints between themselves and with frontal (forehead) bone and nasal cartilages. Nasal cartilages include a septal cartilage most of which is internal and alar cartilages that form sides and tip of the nose as well as much of the nares. Finally, the nasal flaps are made of fibro-fatty tissue – mostly collagen fibers interspersed with fat cells. There are some small accessory nasal cartilages also, but we won’t concern ourselves with these.

Try this: Grip the upper bridge of your nose and wiggle your fingers. Normally, it won’t budge because the nasal bones are firmly-anchored. Slide fingers toward the apex and wiggle it; this part moves easily because it is formed of flexible cartilage. Now, find the juncture between hard and flexible areas; this is where nasal bones meet nasal cartilages.

Photo B

Clinical Correlation #1: ever seen a broken nose? Not a pretty sight. One may look a bit like wee, wild Willie’s nose after the tavern brawl (Starz episode 5, Rent). It was his first time on the road, but being a true Highlander, the lad held his own. The bloody jagged line across the bridge of his nose lies near the juncture between nasal bones and cartilages, a common site to suffer a broken nose.

As you might imagine, nasal fractures range from mild to severe and symptoms include: pain and swelling that persists after 3 days, crooked nose, difficulty breathing through the nose even after swelling decreases, fever and recurrent nosebleeds. If clear fluid starts leaking from an injured nose, get to an emergency room pronto as this could be CSF (cerebrospinal fluid)!

The external nose also has two muscles (Photo C): nasalis (Latin meaning pertaining to the nose) and depressor septi nasi (Latin meaning pull down nasal septum). The alar part of nasalis lifts and flares the nasal alae to open the nares. A transverse part of nasalis compresses the alae to close the nares. Depressor septi nasi aid the transverse nasalis muscles by drawing down the septum.

Photo C

Do we see examples of the nasalis muscles at work in Starz episodes? Aye we do! Jamie’s grand, garrulous (ha) godfather offers a terrific example for our viewing pleasure. Here, dour Murtagh glares at Claire as they scour Scotland for their beloved Lallybroch Laird (Starz episode 114, The Search)! It’s easy to tell if the nasalia (pl.) muscles are contracted because the alae flare deepening the furrow between them and the sides of the nose.

The internal nose consists of two slit-like nasal cavities separated by a midline nasal septum. Nasal cavities begin at the nares as right and left vestibules, each lined with thin skin and coarse hairs that trap unwanted particles (Photo D – left septum). The nasal cavities extend posteriorly ending at the choanae, a pair of openings on either side of the septum that are continuous with the nasopharynx or back of the throat (Photo D).

Each nasal cavity has floor, roof, septal wall and lateral wall. The floor is made of bony palate that separates nasal and oral cavities (Photo D – blue arrow). The septal wall or nasal septum is flat, smooth and divides the paired nasal cavities (Photo D – left side of nasal septum). A whopping seven cranial bones plus the septal cartilage form the nasal septum but these will not be covered in this lesson. When we are young, the septum is typically straight but trauma, disease or age can create a deviated septum, a condition which may interfere with air flow on the narrowed side.

Photo D

Unlike the septal walls, the lateral walls are complex; each is convoluted into three chonchae or turbinates that project like drooping shelves into their respective nasal cavity (Photo E). Humans also have four sets of paranasal sinuses with openings that drain into the lateral walls but these will be covered in a later lesson. The roof of each nasal cavity is described below.

Photo E

Excepting the vestibule, all surfaces of the nasal cavities are covered with mucous membrane (red surfaces in Photos D and E) so named because all cells of the surface layer are living as opposed to skin wherein the topmost cells are dead. The mucous membrane of floor and septal and lateral walls include a surface layer called respiratory epithelium. Deep to the nasal respiratory epithelium are glands which release mucus and watery fluids forming a surface coat that hydrates and moistens the entire mucous membrane (Note: mucous is adj. form and mucus is a noun – these are not misspellings).

Nasal respiratory epithelium includes six types of cells but we will cover only the ciliated cell because it is really special. Photo F isn’t an image of heather covering a Scottish Munro; it is a scanning electron micrograph (SEM) of nasal respiratory epithelium. We have seen SEM images before in skin (# 5 and #6) and inner ear (#25) anatomy lessons. SEM micrographs are 3-D images showing highly magnified surface details. Thus, in Photo F, the pinkish shag carpet is actually cilia, motile “hairs” projecting from the surfaces of ciliated cells. Cilia of the front of the nasal cavities beat toward the nares to kick out mucus and unwanted debris; cilia toward the back of the nasal cavities beat toward the pharynx where debris and mucus can be swallowed or coughed out. Cool, huh?

Photo F | Photo credit: Steve Gschmeissner

Now, let’s return to the scroll-like lateral walls of the nasal cavities. Why the complex shape? First, the shelves increase surface area of mucous membrane to help warm and humidify inspired air before it reaches the delicate lungs (Photo G). Second, air is tumbled as it flows over the chonchae trapping air-borne particles in the mucous film so cilia can move this stuff toward the nares or the pharynx. An ingenious design indeed!

Clinical Correlation #2: Cigarette smoking (are you weary of this topic?) causes respiratory epithelium to be replaced with a more durable type such as lines the mouth. Unfortunately, the replacement epithelium lacks cilia so particles and mucus cannot be properly removed. Further, these changes are not limited to nasal respiratory epithelium but occur throughout the airways even into the lungs and are the basis for smoker’s cough. And, in case you are wondering, yes, routine marijuana smoking causes similar changes to respiratory epithelium. As for e-cigarettes, the jury is still out on this practice because it is new. However, early results indicate that it is also deleterious to respiratory epithelium. Don’t mean to preach… just sayin’! It’s my job, ye ken?

Photo G

Now, a moment for something truly fascinating: deep in the nasal mucous membranes are structures known as swell bodies. It’s true! Would I lie to you? Here’s what they look like. Och, sorry students, wrong image! These are swell bodies but not the swell bodies of nasal mucous membrane (Starz, episode 107, The Wedding)!

Lost me train of thought…Oh, there it is! The mucous membranes of both nasal cavities contain an extensive plexus of vessels labelled “network of veins” in Photo H, a LM (light micrograph) taken of a thin section of nasal mucous membrane after staining with pink and blue dyes.

This extensive plexus of veins constitutes swell bodies of nasal mucosa (in each nasal cavity), a type of erectile tissue like that of male and female phalli (pl.). During sexual arousal, the venous spaces of the phallus fill with blood causing the organ to become turgid and erect. Well, something very similar occurs to the swell bodies of the nasal cavities. YES, it does! Regulated by the brain (hypothalamus), the swell bodies of one nasal cavity fill with blood while those of the opposing side drain. Known as the nasal cycle, every so often the sides flip such that swell bodies of the opposing side engorge with blood while the former full side empties. How long is the interval? Well, it varies from about 30 minutes to a few hours. Normally, we are unaware of the nasal cycle because overall airflow remains constant. Why do we have a nasal cycle? Well, air flow is reduced through the engorged side allowing it to rest and rehydrate. Then the sides flip so the other nasal cavity can recuperate. Isn’t this wondrous? It boggles the mind!

Try this: Slowly inhale and exhale. Can you feel air moving more freely through one nasal cavity? This is the side with empty swell bodies whereas swell bodies are filled with blood on the closed side. Wait an hour or so and see if the sides flip. Note: if you have a deviated septum, active allergies or a cold this phenomenon will be difficult to demonstrate.

Photo H

Lastly, we must consider the roof of the nasal cavities. The roof is endowed not with respiratory epithelium but with olfactory epithelium (Photo I – blue area). Taste buds of the oral cavity detect five distinct qualities of taste, but our noses distinguish hundreds of substances even in minute quantities. Being more diversified, olfaction (smell) also aids our sense of taste. And to further refine the issue, we detect odors during inhalation but the taste boost occurs during exhalation.

Photo I

Olfactory epithelium is composed of numerous olfactory neurons (nerve cells) which collectively form the olfactory nerve or Cranial Nerve I (Photo J). Airborne molecules bind to the surface of the olfactory neurons causing them to depolarize. This electrical response travels along the olfactory bulb (Photo J) before distributing to olfactory areas of the brain where smell is perceived and interpreted.

Lastly you should know that our ability to detect odors decreases with age, a change usually more pronounced in men than in women. People often do not recognize the loss unless they also experience a decreased sense of taste.

Photo J

Clinical Correlation #3: Neurons are terminal cells meaning early in life they cease to divide and proliferate. Olfactory epithelium is exceptional because these neurons retain the amazing ability to divide and replace themselves throughout life.

You all ken that major spinal cord injuries do not repair because surviving neurons cannot divide to replace damaged or dead neurons. Well, recently, Polish doctors transplanted olfactory neurons (his own) into the spinal cord of a man paralyzed from the chest down in the world’s first attempt to reverse paralysis using this technique. The hope is that olfactory neurons transplanted to the spinal cord will proliferate, connect with and stimulate his paralyzed muscles. You can follow his progress at Spinal Cord Injury Zone. Let’s send him and his health care team our best wishes for success!

Now, for more fun stuff: let’s peruse Starz images and book quotes for more about splendid noses; there are many!

After being whacked on the heid by Murtagh’s dirk, Claire awakens astride a horse and immediately analyzes his fine fecund funk (Starz episode 101, Outlander):

“I knew it wasn’t a dream. My erstwhile savoir fairly reeked of odors too foul for any dream I might conjure up.”

Claire meets Jamie in a stone cottage and a whole lot of “playing doctor” ensues enabling Jamie to erm, mount a steed. Snort! Dougal jerks puir Claire around and then hoists her up on Jamie’s horsie (Starz episode 101, Sassenach and Outlander book)!

“With a slight grunt, he boosted me into the saddle in front of Jamie, who gathered me in closely with his good arm… He smelt strongly of woodsmoke, blood, and unwashed male, but the night chill bit through my thin dress and I was happy enough to lean back against him.”

Next, Claire uses her knowing nose after Dougal and his merry men lay waste to a raft of redcoats at Cocknamon Rock (Starz, episode 101, Sassenach and Outlander book).

“Someone passed a flask to Jamie, and I could smell the hot, burnt-smelling liquor as he drank. I wasn’t at all thirsty, but the faint scent of honey reminded me that I was starving…”

Fast forward to swell bodies! Going nose-to-nose with her young gallant on their wedding night, Claire considers Jamie’s splendid nose (Starz episode 107, The Wedding)! Herself writes in Outlander book:

“’My mother was a MacKenzie, though. Ye’ll know that Dougal and Colum are my uncles?’ I nodded. The resemblance was clear enough, despite the difference in coloring. The broad cheekbones and long, straight, knife-edged nose were plainly a MacKenzie inheritance.

Now, here’s Jamie’s 18^th century colorful counsel about sharing one’s armpit aura with another creature (Starz episode 107, The Wedding and Outlander book):

“He raised one arm, displaying a soft tuft of cinnamon-colored hair. ‘You rub your oxter over the beast’s nose a few times, to give him your scent and get him accustomed to you, so he won’t be nervous of ye.’ …’That’s what you should have done wi’ me, Sassenach’….’Then I wouldn’t have been skittish.’”

Snort!

A skittish Scottish Scot? Har, har! Ready for something truly amazing! Experiments show that mice chose genetically diverse mates based on smell. Fine and dandy, but what about humans? Have you heard of the “sweaty T-shirt” experiment? In 1995, a Swiss zoologist devised an experiment to determine if women prefer the odor of some men over others. Male volunteers wore clean T-shirts and female volunteers blindly smelled shirt odor to evaluate it for intensity, pleasantness and sexiness. Overall, the women preferred the smell of men whose MHC genes differed from their own. Whaaat? What is MHC? MCH (major histocompatibility complex) genes generate molecules that enable our immune system to recognize and destroy invaders; the more diverse the parental MHC genes the stronger the immune system of their offspring, an advantage in destroying pathogens. The study results suggest that evolution has provided humans with a transmitter (odor/pheromone) and receiver (olfactory epithelium) of genetic information that could influence mate choice. Wow!

Now, you might think Claire is just resting her face against Jamie’s back to recuperate after hiking around this braw Scottish mountain (Starz episode 107, The Wedding)! But, she was clearly sniffing to detect his MHC. Her nose knows he is the King of Men! Yup, he’s a keeper! Herself explains (Outlander book):

“His pleasant musky smell mingled with the harsh scent of linen. “Take off your shirt,” I said … He smelled faintly of soap and wine…”

And he did! Take off his shirt, I mean. Yerp!

Hey, hey, come back! In summary, the external nose adds contour and expression to our faces while the internal nose cleanses and humidifies the air we breathe as well as provides us with the ability to smell a broad and fascinating array of molecules. Do you appreciate your sniffer? Is it as keen as Claire’s? Let’s be grateful to the sense of olfaction for the richness and joy it adds to our lives!

Be Glad Your Nose is on Your Face

Jack Prelutsky, 1940

Be glad your nose is on your face,
not pasted on some other place,
for if it were where it is not,
you might dislike your nose a lot.

Imagine if your precious nose
were sandwiched in between your toes,
that clearly would not be a treat,
for you’d be forced to smell your feet.

Your nose would be a source of dread
were it attached atop your head,
it soon would drive you to despair,
forever tickled by your hair.

Within your ear, your nose would be
an absolute catastrophe,
for when you were obliged to sneeze,
your brain would rattle from the breeze.

Your nose, instead, through thick and thin,
remains between your eyes and chin,
not pasted on some other place–
be glad your nose is on your face!

A Deeply Grateful,

Outlander Anatomist

photo creds: Netter’s Atlas of Human Anatomy, 4^th ed., Sony Pictures, Starz, www.rci.rutgers.edu (schematic of olfactory epithelium), www.sciencephotolibrary.tumblr.com (SEM of respiratory epithelium)

August 4, 2015August 3, 2015

Colum’s Legs and Other Things, Too!

Thanks for running to class today, Outlander anatomy students! Today’s Anatomy Lesson #27 is on the Leg. Upper and lower limbs are both fascinating and complex puzzle pieces of our human anatomy (Photo A). Four Anatomy Lessons (#19, #20, #22, #23) have covered the upper limb but only one dealt with the lower limb (Anatomy Lesson #7). This leg-a-thon has been slooow in coming, but Colum’s legs are begging for some well-deserved attention!

Photo A: Dream Object by Jim Shaw

We all know that Colum’s legs captured Claire’s attention from the get-go. Here, her glass face shows what she thinks “plain and clear” (Starz episode 102, Castle Leoch). She’s surprised when the laird catches her riffling through his personal letters and books and then she is startled by his unusual physique.

Herself records Claire’s thoughts (Outlander book):

“At the moment, though, my discomfort arose from the fact that the beautifully modeled head and long torso ended in shockingly bowed and stumpy legs. The man who should have topped six feet came barely to my shoulder. … ‘I welcome ye, mistress,’ he said, with a slight bow. ‘My name is Colum ban Campbell MacKenzie, laird of this castle.’ ”

Colum’s bowed and twisted legs burden him with two “gifts that keep on giving”: pain and discomfort. Scientific explanations for his disability are coming up soon but first we must learn normal anatomy of the leg. So let’s get a leg up and start trotting!

In Anatomy Lesson #7, “Jamie’s Thighs or Ode to Joy,” we learned that anatomists define the leg differently than is common. In anatomy, the lower limb is divided into thigh, the region between hip and knee joints; leg, the region between knee and ankle joints; and foot, the remainder of the limb (Photo B). Colum’s entire lower limbs are affected by his disability but as that entails too much anatomy for a single lesson, we will focus on the anatomical leg.

Photo B

As always, we begin with the bony foundation. The lower limb contains 29 bones, one fewer than the upper limb: the thigh contains one bone, the leg contains two and the foot has 26.

The femur or thigh bone is the longest and by most measures the strongest bone of the human body (Photo C – right femur). Its bony details (and Jamie’s thighs) were covered in Anatomy Lesson #7 so we will skip them today.

Photo C

Each leg contains two bones, the tibia situated medially (closer to body midline) and the fibula positioned laterally (away from body midline). Although not shown in Photo D, strong ligaments bind tibia and fibula to each other and also to femur and a few foot bones.

Parts of the sturdy tibia are subcutaneous thus its sharp anterior border and medial surface are easily palpated. Its proximal (near) end forms a bony plateau for the knee joint and its distal (far) end forms the medial malleolus or inner ankle bone (Photo D).

The needle-shaped fibula (Latin meaning clasp – as the pin of a brooch) is difficult to palpate except at its ends: the head forms a bony knob at the outside of each knee and the lateral malleolus is the outer ankle bone (Photo D). Fibulae are useful because surgeons can harvest most of their lengths for bone grafts (e.g. mandibular reconstruction) with little deficit as long as both fibular ends are left intact.

Try this: Place fingers on the front of your leg. Palpate the sharp anterior border of tibia or shin bone, the part that gets barked on projecting surfaces. Ouch! Move fingers toward the inside of your leg and feel the hard, flat medial surface of tibia. Move fingers to the inner ankle and tap the bony medial malleolus of tibia.

And try this: Next, move fingers to the muscle mass at the side of your leg; it covers most of fibula except at each end. The bony knob you feel near the knee is the head of fibula. Find the bony outer ankle or lateral malleolus of fibula. Together, medial and lateral malleoli (pl.) form a strong box-like frame for a foot bone which will be covered in a later lesson (Photo D- green arrow).

Photo D

The leg contains 12 muscles; we’ll cover four. The first muscle is tibialis anterior (Anatomy Lesson #9), the muscle savaged by a boar’s tusk at the tynchal (Starz episode 104, The Gathering). Tibialis anterior is a strong fleshy muscle that hugs the outer surface of the tibia. It arises from the tibia and inserts into a foot bone (Photo E – right tibialis anterior). Contraction dorsiflexes the foot meaning it lifts the toe-end of the foot toward the sky, an action critical for walking and running. It also helps invert the foot, meaning to turn the sole of foot toward the midline.

Try this: Plant a shoeless foot on the floor. Leave the heel planted but lift the toe-end of your foot skyward. This is dorsiflexion. Replant the foot and turn sole inward to face the midline; this is inversion (some practitioners call this supination). Return the foot to dorsiflexion and palpate the tense fleshy muscle just lateral to your tibia; this is tibialis anterior.

Photo E

Want to see a really cute tibia (red arrow) and tibialis anterior muscle (blue arrow)? Of course ye do! Here is Claire the morning after (Starz episode 107, The Wedding). Yep…her curvaceous legs are beautiful and her crossed toes make her look soooo innocent but we all ken what those toes did last night! Jamie, weel, he’s hungry. How about a bite, Claire?

At the side of the leg is fibularis longus (aka peroneus longus). A long spindle-shaped muscle that arises from head of fibula, its tendon passes under the foot and inserts on a bone near the instep (Photo F). Fibularis longus contracts to evert the foot meaning it turns the sole away from the body midline. Think of a novice ice skater: ankles knock together and soles turn outward – this is eversion of the feet. Fibularis longus also helps plantar flex (point) the foot.

Try this: Plant a shoeless foot on the floor. If you can, turn your foot so the sole faces to the side and your inner ankle moves closer to the ground. This is eversion (some practitioners call this pronation) of the foot. With the foot in this position, feel the tense muscle running down the outside of your fibula; this is fibularis longus. Now point the foot, this is plantar flexion also aided by fibularis longus.

Photo F

The back of the leg contains seven muscles but we will cover only two. First is gastrocnemius (Latin and Greek meaning stomach of the leg); this odd name reflects the bulging shape of the calf created by gastrocnemius. This muscle spans two joints: knee and ankle. It also has two heads, one arising from each side of the femur (Photo G). The heads unite high in the leg but about midway down the calf the muscle gives way to the calcaneal or Achilles tendon. The longest and strongest tendon of the body, it inserts into the calcaneus or heel bone (Photo G, green arrow).

Photo G

Contraction of the gastrocnemii (pl.) flexes the legs at the knee joints and plantar flexes (points) the feet. These are powerful muscles and each is active during fast movements such as running, jumping and dancing.

Gastrocnemii are verra active during a shinty game (Starz episode 104, The Gathering). Run ruaidh Jamie! Big bad Uncle Dougal is hot on your handsome Highland heels! Run, run as fast as you can; you can’t catch the ginger-haired man!

Covered by boots, we canna see the gastrocnemii but they are also busy as Murtagh, um, “executes” his version of the Highland sword dance (Starz episode 114, The Search).

The soleus (Latin meaning sandal) is a large, flat muscle deep to each gastrocnemius. Soleus arises from the back of tibia and fibula and joins gastrocnemius to form the Achilles tendon (Photo H). Because gastrocnemius and soleus share the Achilles tendon, some anatomists consider them a single muscle, the triceps surae (Latin meaning three-headed calf muscle). Soleus crosses only the ankle joint so it helps plantar flex the foot. But equally important, soleus is a postural muscle that helps us stand aright; if not for its constant backward pull, we would do a face-plant!

Now, here’s an interesting factoid: besides plantar flexion and posture maintenance, soleus helps prevent stasis of venous blood. A large leg vein (posterior tibial) passes deep to soleus so when the muscle contracts, venous blood is moved towards the heart against gravity. For this contribution, the soleus is also called the sural pump. This is so important that some health providers recommend soleus exercises for inactive patients to help prevent deep venous thrombosis (DVT or blood clots). And, smart passengers on long air flights should flex and point their feet every couple of hours (activates the soleus pump), walk around, wear loose-fitting clothes, etc., to help prevent blood clots.

Photo H

A comment or two about the calcaneal/Achilles tendon, the most commonly injured tendon of the human body! Explosive actions such as jumping or a sudden pushing off can tear the tendon or avulse it from its insertion on the heel bone. Achilles tendon injury is much more common in males than females and accompanies increased athletic activity (especially after years of sedentary lifestyle), the effects of aging or the use of some antibiotics.

And, just so we understand its origins, the Achilles tendon is named for the mythical Greek hero Achilles who was slain during the Trojan War when Paris’ poisoned arrow hit the heel, his only vulnerable body part (Photo I). As a wee lad, his mom held him by the heel and dipped him in the River Styx to grant him indestructibility but, sadly, that heel didna get baptized!

Photo I

Want to see a manly example of an Achilles tendon (Starz episode 112, Lallybroch)? Weel…Jamie has one! First off, the lad has long tibiae and fibulae (pl.) which lend his calves a lean, lengthy leg-look. Red arrows mark the junctions between Jamie’s gastrocnemius muscles and his Achilles’ tendons which continue down the legs to end at the heel bones (blue arrow). Nice runner’s legs, laddie! Getting into that mill pond? Take good care; Claire willna like it if ye freeze off her fav body part!

Now, we are done with normal anatomy, so let’s apply it to Outlander! Returning to Colum MacKenzie (Starz episode 104, The Gathering), Claire’s considers Colum and his brother, Dougal (Outlander book):

“Now there was a strange man. A cultured man, courteous to a fault, and thoughtful as well, with a reserve that all but hid the steely core within. The steel was much more evident in his brother Dougal. A warrior born, that one. And yet, to see them together, it was clear which was the stronger. Colum was a chieftain, twisted legs and all. Toulouse-Lautrec syndrome. I had never seen a case before, but I had heard it described. Named for its most famous sufferer (who did not yet exist, I reminded myself), it was a degenerative disease of bone and connective tissue.”

Question #1: Does Claire correctly diagnose Colum as suffering from Toulouse-Lautrec syndrome? Let’s take a closer look.

Henri de Toulouse-Lautrec (aka Henri Marie Raymond de Toulouse-Lautrec-Monfa, 1864-1901) was a 19^th century artist who garnered fame as a painter, printmaker, illustrator and draughtsman. A contemporary of Gauguin and van Gogh, his work embraced the colorful, daring and glaring life of Bohemian Paris and his subjects were often members of that social stratum. His works are highly valued. Ten years ago, his painting of a young laundress (La blanchisseuse, 1889) sold for a record US $22+ million (Photo J)!

Photo J

Toulouse-Lautrec was the first born child of an aristocratic French family whose parents were first cousins. By eight years of age, his talent for drawing and painting had surfaced, but problems with growth and development soon followed. At 13, Henri fractured his right femur and a year later, his left, but the breaks never healed properly. His legs ceased to grow such that as an adult, he stood 4’ 8” (1.42 m). His trunk was adult-sized but his legs remained those of a child (Photo K).

Fast forward to 1962; a pair of French physicians (Maroteaux and Lamy) described a rare clinical entity (1.7/1 million births) dubbed pycnodysostosis (Greek meaning dense, defective condition of bone) or Toulouse-Lautrec syndrome. Pycnodysostosis is inherited if a child receives a recessive gene for the disease from each parent, an unlikely outcome unless parents are closely related. However, because genetic testing was unknown during Henri’s lifetime, it is surmised that he suffered from this disease (there are other possibilities).

Photo K

Now, lace up your shoon, gobble down your haggis and bear with me for a bit of microscopic anatomy. We humans think of our skeletons as static structures but this is so not so! Each bone is a living organ that is restructured and remodeled throughout life by action of two bone cells: osteoblasts (bone-forming cells) that make bony matrix and osteoclasts (Greek meaning bone + broken) that breakdown bone. Osteoclasts (Photo L – blue dashed line) are multinucleated giant cells many times larger than our red blood cells (Photo L – red dashed line). A third bone cell, the osteocyte, also has bone activity but we will not cover this cell today. Our bones are remodeled as we grow, age, gain or lose weight, experience pregnancy, change exercise regimes, or mend broken bones; all possible because of osteoblasts and osteoclasts.

It turns out that pycnodysostosis/Toulouse-Lautrec sufferers cannot make an enzyme (Cathepsin K) essential for protein breakdown. Because osteoclasts lack this enzyme these cells cannot break down bone; thus, bones neither remodel nor mend properly. Make sense?

Photo L

Lacking just ONE enzyme, Toulouse-Lautrec sufferers experience these painful and debilitating symptoms:

Stature: adult males stand less than 150 cm (4’ 11’); adult females are shorter.
Bones: bones are dense because osteoclasts cannot resorb them. Bones are brittle and fracture easily especially weight-bearing bones of the lower limbs, mandible (Anatomy Lesson #26) and clavicles (Anatomy Lesson #3).
Skull: bones of forehead (frontal bone), back of head (occipital bone), nose and mandible as well as the teeth do not form properly. The anterior fontanel (‘soft spot” on top of the head) remains widely open, possibly why Toulouse-Lautrec consistently wore a hat.
Hands: skin over the back of fingers is deeply wrinkled; nails are flat and grooved. Distal phalanges are short (Anatomy Lesson #22 & Anatomy Lesson #23).
Spine: defective vertebrae cause the spine (Anatomy Lesson #15) to curve laterally (scoliosis).
Impotency and/or sterility: Toulouse-Lautrec purportedly contracted syphilis from a prostitute who served as his model – his history suggests he was not impotent but he is not known to have sired children. Alcoholism (absinthe for pain), tertiary syphilis and his weakened constitution took his life at 37. Colum was apparently sterile because Dougal ensured his bloodline by begetting Hamish with Letitia (Starz episode 109, The Reckoning). Dougal also assured Colum “that she was tender and sweet as a ripe peach and all that a man could want in a woman” (Outlander book) implying that Colum did not know his wife sexually (impotent).

Answer to Question #1: Yes, Claire very likely correctly diagnosed Colum’s disability as Toulouse-Lautrec syndrome (pycnodystosis).

Question #2: Does Diana’s description of Colum’s symptoms match with those of Toulouse-Lautrec syndrome? You be the judge. Claire reflects in Outlander book:

“Victims often appeared normal, if sickly, until their early teens, when the long bones of the legs, under the stress of bearing a body upright, began to crumble and collapse upon themselves. The pasty skin, with its premature wrinkling, was another outward effect … that characterized the disease. …. As the legs twisted and bowed, the spine was put under stress, and often twisted as well, causing immense discomfort to the victim. … Because of the poor circulation and the degeneration of connective tissue, victims were invariably sterile, and often impotent as well.”

And another quote from Outlander book: Here, Ned Gowan explains to Claire:

“Colum was a whole man to the age of eighteen or so,” … “but soon after the marriage he had a bad fall, during a raid. Broke the long bone of his thigh, and it mended poorly.” …“And then,” Mr. Gowan went on with a sigh, “he rose from his bed too soon, and took a tumble down the stairs that broke the other leg. He lay in his bed close on a year, but it soon became clear that the damage was permanent.

Okay, let’s all be the judge!

Answer to Question #2. My opinion: Claire’s description and the visuals of Colum’s legs almost exactly match the symptoms of Toulouse-Lautrec syndrome or pycnodysostosis. Colum’s thigh muscles are abnormally twisted and grooved (above photo – red arrows) due to his poorly mended femora (pl.). His right fibula also appears to have been broken and mended badly (below photo – blue arrow) and his twisted Achille’s tendon (below photo – red arrow) is displaced laterally. Remember Claire’s offer to massage the base of Colum’s spine rather than his legs? Nerves innervating the legs emerge near the base of the spine explaining why spinal massage of that region might provide temporary relief. Colum suffered greatly with his laird’s legs but make no mistake: “this clan remains under the charge of this man!”

The visual presentation of this terrible syndrome was very convincing and well done. Way to go Colum, Claire, Diana and CGI team!

Here is an interesting and apropos tidbit about a cute cat (Photo M). The Scottish fold cat (aka Highland Fold, Longhair (Laoghaire?), Longhair Fold) is a domestic cat with ears that fold forward toward the nose. They also suffer from distorted limb bones and arthritis. The breed is the result of a genetic mutation in a single barn cat named Susie (Perthshire, Scotland, 1961). But most pertinent here, the Scottish fold syndrome belongs to the same group of cartilage and bone disorders as Toulouse-Lautrec syndrome. Yep, it does!

Photo M

Now, let’s end this lesson with some fun frivolous facts about legs (here meaning the entire lower limb)!

Michael Flatley (Riverdance) insured his legs in 1999 for US $40 million.
In 1836, Mexican General Santa Anna held an elaborate state funeral for his amputated leg.
The average person takes 6,000 -9,000 steps per day: 28,000 – 42,000 miles in a 70 year lifespan. This exceeds the circumference of the globe!
The “legs up the wall” yoga pose relieves anxiety, stress and tired legs (lie on back near a wall. Lift lower limbs up the wall and scoot butt against the wall). It feels marvelous as blood drains from the lower limbs!
Svetlana Pankratova of Russia purportedly has the longest legs of any woman in the world – at 1.32 m or 4.33 ft. (Does the Guinness rep realize that she is wearing heels? Not exactly a scientific measurement). Her hip joints and my oxters are at the same height!

Be grateful! Kick your own legs up in the air if ye can and offer a hand to those whose legs dinna work quite so well!

A Deeply Grateful,

Outlander Anatomist

Photo creds: Netter’s Atlas of Human Anatomy, 4^th ed., Starz, www.greekmyths-greekmythology.com (Achilles), www.montessoricats.com (Buddha cat), www.news.asiatown.net (Svetlana Pankratova), www.praz-delavallade.com (Jim Shaw painting), www.reddit.com (Scottish Fold cat), www.wikipedia.org (La blanchisseuse and Toulouse-Lautrec photos), Robert M. Hunt (B&W osteoclast)